Become a patient advisor to the province

ask for your feedback on certain policies and programs that affect patients and their families

invite you to participate in patient and family engagement events

keep you up to date on volunteer opportunities

First name *

Last name *

Street address *

City/Town *

Postal code *

Email address *

Primary phone number

Secondary phone number

What statement best describes you? Select all that apply.

I’m a patient

I’m a caregiver

I’m a family member of a patient

I’m interested in health care issues

Optional demographic questions

Your answers to these questions will help us tailor how we engage you on topics you’re interested in. Completing this section is optional.

What is your age?

15 years of age or under

16 to 24 years old

25 to 34 years old

35 to 44 years old

45 to 54 years old

55 to 64 years old

Over 65 years old

Prefer not to say

What is your gender identity? Select all that apply.

Woman

Man

Transgender

Two Spirit

Genderqueer

Other

Prefer not to say

Please specify

Do you identify as Indigenous (First Nations, Métis, Inuit)?

Yes

No

Do you identify as a member of a racialized minority?

Yes

No

Do you identify yourself as (select all that apply):

African

Caribbean

East Asian

European

Indigenous (First Nations, Métis or Inuit)

Middle Eastern

Mixed ethnicity

South American

South Asian

Southeast Asian

Other

Prefer not to say

Please specify

Do you identify as Francophone?

Yes

No

Prefer not to say

Do you identify as a person with a disability?

Yes

No

Prefer not to say

What is the highest level of education that you have completed?

Elementary school

High school

College

Technical/trade school/apprenticeship

Undergraduate degree

Graduate/Professional degree

Other

Prefer not to say

Please specify

Which of the following best describes your current employment situation?

Employed full-time

Employed part-time

Small-business owner

Self-employed

Homemaker

Student

Retired

Unemployed

Other

Prefer not to say

Please specify

What is your combined household income (before taxes)?

Less than $25,000

$25,000-$49,999

$50,000-$74,999

$75,000-$99,999

$100,000-$149,999

$150,000-$199,999

$200,000+

Prefer not to say

How would you describe your community? Select all that apply.

Urban

Suburban

Northern

Rural

Remote

On Reserve

Prefer not to say

In the past year, how many times have you or the person you are caring for had direct contact with a health care provider (e.g. a nurse, physician, clinic, hospital or other health care worker or organizations)?

0 times

1-4 times

5-9 times

10 or more times

Your privacy matters

Your privacy is important to us. Do not include any information that identifies a friend, family member or other person in your responses. If you choose to provide personal information in this form, the information will be handled according to our Privacy Statement.

Privacy statement

By clicking the submit button at the bottom of this form, you are indicating that you consent to the ministry’s collection of the personal information you have provided.

The ministry’s collection of this personal information is necessary for the proper administration of the provincial patient advisor initiative. It will be used by the ministry only for the purpose of asking for your feedback on certain policies and programs that affect patients and their families, inviting you to participate in patient and family engagement events, and keeping you up to date on patient engagement opportunities.

Your information will not be placed on mailing lists or released to any third party, except as may be authorized by law.

If you have any questions about the ministry’s collection or use of this information, please contact the Manager, Health System Quality and Funding Division, Ministry of Health and Long-Term Care:patientengagement@ontario.ca
phone: 416-325-3058
Hepburn Block 5th Floor- 80 Grosvenor St
Toronto ON M7A 1R3